Pulmonology Coding Alert

Recognize the restrictions of a DOS edit.

Occasionally, a medical report will come across your desk with an encounter that isn’t a cut-and-dried coding case. These cases may require a little more research and possibly expecting a denial, so you can accurately present your practice’s case for reimbursement.

Check out one puzzling scenario below and learn an approach to reporting the encounter.

Examine This Therapeutic Bronchoscopy Encounter

Scenario: A patient presents to your outpatient clinic for therapeutic aspirations of their bronchus via bronchoscopy. During the procedure, the provider performed two therapeutic aspirations without fluoroscopic guidance. The physician listed the postprocedure diagnosis as an abscess of the right bronchus.

Now that you’ve examined the scenario, learn your coding options for this not-so-common scenario.

Choose the Correct Procedure Codes

In the scenario presented above, the provider performed two therapeutic aspirations of the patient’s right bronchus via bronchoscopy without imaging guidance. Some coders may find it tempting to report 31646 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with therapeutic aspiration of tracheobronchial tree, subsequent, same hospital stay) appended with modifier 52 (Reduced services). However, 31646’s descriptor includes the phrase “same hospital stay,” which indicates the code is appropriate only for services provided in an inpatient setting, and the provider performed the procedure in an outpatient clinic.

Modifier 52 applies only when a provider doesn’t perform the complete procedure as described in the code descriptor. The modifier doesn’t apply to services performed in a different setting from what’s listed in the code descriptor. At the same time, the descriptor features the phrase “when performed,” which means the procedure code is appropriate regardless of whether the provider uses the imaging guidance. That means you should not append modifier 52 to indicate the lack of fluoroscopic guidance.

According to the American Thoracic Society’s January 2018 issue of ATS Coding & Billing Quarterly, 31646 “describes the same procedure and is utilized when the procedure is repeated during the same hospital stay,” and “would not be appropriate to use for a procedure done in the outpatient setting” (www.thoracic.org/about/newsroom/newsletters/coding-and-billing/resources/2018/cbq_january18.pdf).

Code 31645 (… with therapeutic aspiration of tracheobronchial tree, initial) is the correct code to assign to report the procedures performed the outpatient setting as described in the scenario above.

Don’t forget the diagnosis: You’ll assign J98.09 (Other diseases of bronchus, not elsewhere classified) to report the documented abscess of the right bronchus diagnosis.

Remember to Review Your Payer Preferences

In the scenario above, the provider performed multiple therapeutic aspirations, so can you receive reimbursement for the multiple procedures? Your best approach is to start by reviewing your individual payer preferences. You may even need to contact the payer regarding this uncommon scenario to see how to report the multiple same-day bronchoscopies with therapeutic aspirations in an outpatient setting.

Depending on your payer’s preferences, one option you have is to assign two separate line items of 31645 with a modifier appended to the second line item. “I would select the modifier that best represents the scenario, and report it on a separate line item,” says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia.

The acceptable modifiers for 31645 include:

• 59 (Distinct procedural service)
• 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care profes­sional following initial procedure for a related procedure during the postoperative period)
• 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period)
• XE (Separate encounter, a service that is distinct because it occurred during a separate encounter)
• XP (Separate practitioner, a service that is distinct because it was performed by a different practitioner)
• XS (Separate structure, a service that is distinct because it was performed on a separate organ/structure)
• XU (Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service)

Reviewing your payer policies and contacting the payer to receive confirmation is crucial in your claim submission process. Some payers may have information that allows reimbursement for multiple therapeutic aspirations on a single date of service (DOS), where other payers’ policies may exclude it.

For example, according to the first quarter 2023 Medicare Medically Unlikely Edits (MUEs), 31645 carries an MUE of “1” (www.cms.gov/medicare-medicaid-coordination/national-correct-coding-initiative-ncci/ncci-medicare/medicare-ncci-medically-unlikely-edits). An MUE value is the maximum number of units Medicare typically allows by the same provider for the same beneficiary on the same date. In this case, Medicare deems that the physician could provide only one instance of 31645 on a given date.

Code 31645’s MUE Adjudication Indicator (MAI) of “2” indicates the code is a date of service (DOS) edit — or a “per day” edit. According to Chapter I, Section V, of the National Correct Coding Initiative Policy Manual for Medicare Services, a DOS edit means that the provider should be able to perform the procedure or service only once per DOS, and anything beyond that “would be considered impossible because it was contrary to statute, regulation, or subregulatory guidance” (www.cms.gov/files/document/medicare-ncci-policy-manual-2023-chapter-1.pdf).

Additionally, 31645’s descriptor includes “initial,” which indicates the procedure code can be reported only once on a given DOS. The rationale is that a physician could not provide two initial procedures on the same DOS.

Using Medicare as an example, with the CPT^® code descriptor and Medicare policies, you’ll need more than just a claim form to receive reimbursement for the multiple therapeutic aspirations. “Demonstrating the need for two line items of 31645 on a given date will require submission of adequate documentation,” Pohlig says.

Prepare a Possible Appeal

Since this scenario doesn’t happen very often, it’s likely that your claim will receive a denial. When that occurs, you’ll need to prepare your appeal for reimbursement by showing that the physician had a reason to perform the multiple procedures.

“If there is no additional guidance from the payer, the practice can realistically expect to have to appeal with the progress note (e.g., reason for both services), the procedure reports, and the specialty society billing recommendations,” Pohlig says.

While certain payer policies, such as Medicare, may indicate multiple therapeutic aspirations cannot be reimbursed for a single encounter, specialty society billing recommendations may offer precedents where similar cases have received reimbursement in the past. As always, reviewing your individual payer policies is the best starting point for handling rare encounters like the one presented.